Mastectomy for tumor
=Introduction= Mastectomy is the definitive treatment for breast cancer or DCIS. Before approaching the specimen, gather some information about the case: *What was the clinical problem? **Skin and nipple abnormality **Mass **Calcifications **MRI enhancement *What happened before mastectomy? **FNA or core biopsy only ***Significance: a clip may be present. **Excisional biopsy (partial mastectomy) ***Significance: a biopsy cavity may be present. **Excision with margin issues ***Significance: a biopsy cavity may be present. **Neoadjuvant chemotherapy ***Significance: there may be treatment effect. *Where was the cancer? **Radiology reports will tell you the location and number of lesions. A simple mastectomy specimen consists of the breast only. A modified radical mastectomy includes the axillary tail, and you must examine the tail specifically for nodes. =Fresh Handling= *Consult radiology reports and clinical history to determine the clinical scenario and guide your gross inspection. *Measure the breast, skin ellipse, nipple-areola complex and nipple. *Orient the breast using the surgeon’s sutures. *Ink the breast: **Anterosuperior: blue **Anteroinferior: green **Deep: black *Note that margins are seldom an issue in these specimens. The color is mostly for orientation. *Place the breast face-down on the table, oriented. *Section into quadrants using a Tissue-Tek knife, then section further in a pinwheel fashion. *Find the lesion or area of interest and document its characteristics: **If tumor: ***Measurements in three dimensions. ***Clock-face position (e.g., 9 o’clock) and/or quadrant. ***Distance from nipple. ***Distance from closest margin. ***Appearance of cut surface. **If biopsy cavity: ***Dimensions ***Clock-face position ***Distance from nipple ***Appearance of cavity wall (hemorrhagic, fibrotic) *If tumor is present and large, take tumor and normal for tissue banking. *Fix specimen in a large quantity of formalin. =Grossing In= If the specimen was thoroughly described in the fresh state, then most of the work is already done. *Submit sections: **Biopsy cavity in toto or representative if large. **Focus on area that prompted the mastectomy (e.g., anterior of cavity, if the anterior margin was positive on the biopsy) **Tumor in toto or up to 4 blocks. **1-2 sections of black-inked margin deep to area of interest **2 representative sections of each quadrant (UI, UO, LI, LO) **1 section of nipple **Other suspicious foci **All intramammary lymph nodes *Examine the axillary tail: **Amputate the tail **Section through to find lymph nodes. There may be areas of scarring if there has been a prior sentinel node biopsy. **Submit all nodes. If large nodes are bisected, document this in your dictation. Include scarred areas since they may or may not include tumor. Submit the case in a bucket designated for “breast”, “fat”, or “16 hour” processing (all of these mean the same thing). =Sample Dictation= Specimen #___ is received fresh, labeled with the patient’s name and medical record number, designated “______--“ And consists of an oriented/unoriented “Modified Radical Mastectomy/ Simple Mastectomy/ Simple skin sparing mastectomy” specimen, measuring ___ x ___ x ___ cm, with an overlying ellipse of skin measuring ___ x ___- x ___ cm, with the nipple-areola complex measuring ___ x ___ x ___ cm and the nipple measuring ___ x ___ x ___ cm. The skin and the nipple appear grossly unremarkable. No subareolar mass is palpated. / OR The skin shows an ill-defined, ulcerated, red-tan lesion measuring – x ___ x ___ cm. The nipple is everted /retracted, showing ulceration. The specimen is received oriented with a suture indicating the axillary tail and is inked as follows: Anterior-superior margin: Blue; Anterior-Inferior margin: Green; and Deep/Posterior margin: Black. The specimen is serially sectioned to reveal (predominantly adipose tissue with) approximately ___ % of fibroglandular stroma (OR the breast tissue is approximately ___ % stroma). An ill-defined, firm, fibrotic area, probably representing the prior biopsy site, is identified, measuring ___ x ___ x ___ cm, located in the UOQ, LOQ, LIQ, UIQ, situated ___ cm from the lesion/mass and ___ cm from the closest ___ margin (margins)/ OR situated ___ cm from the anterior-superior, ___ cm from the anterior-inferior and ___ cm from the deep-posterior margins/ OR abutting the ___- margin. A clip is/ is not identified in this prior biopsy site. OR A solitary/___, ovoid/round/irregular (spiculated), solid/cystic, well/poorly circumscribed, nodular mass, measuring ___ x ___ x ___ cm, ___- in color, firm/soft/hard/schirrous in consistency, well/poorly encapsulated, with a homogenous/heterogeneous cut surface, with/without areas of hemorrhage and necrosis, located in the UOQ, LOQ, LIQ, UIQ, situated ___ cm from the closest ___ margin (margins)/ OR situated ___ cm from the anterior-superior, ___ cm from the anterior-inferior and ___ cm from the deep-posterior margins/ OR abutting the ___ margin, is identified. (An ill-defined, firm, fibrotic area, probably representing the prior biopsy site, is identified, measuring ___ x ___ x ___ cm, located in the UOQ, LOQ, LIQ, UIQ, situated ___ cm from the lesion/mass and ___ cm from the closest ___ margin (margins)/ OR situated ___ cm from the anterior-superior, ___ cm from the anterior-inferior and ___ cm from deep-posterior margins./ OR abutting the ___ margin. A clip is/ is not identified in this prior biopsy site). =Review and Signout= 1. Left breast and axillary tail, mastectomy: :A. Invasive ductal carcinoma, ___ cm, (high, intermediate, low) grade, (resection margins free of involvement) or (___ cm from the superior/inferior/etc. resection margin), smd (F9). :B. Associated ductal carcinoma in situ, solid and/or cribiform pattern(s) (with comedo-type necrosis), (resection margins free of involvement) or (___ cm from the superior/inferior/etc. resection margin). :C. Skin and nipple, no carcinoma identified. :D. ___ axillary lymph nodes, no carcinoma identified (0/___) or Metastatic adenocarcinoma in ___/___ axillary lymph nodes (___/___). : :A. Breast with biopsy site changes (or biopsy cavity), no residual carcinoma identified. :B. ___ lymph nodes, no carcinoma identified (0/___). ---- Return to Breast Grossing